Study 1 analysis identified five main themes (social interaction, credibility, relevance, information processing, and practicalities) of perceived effectiveness of training components, each of which contained several sub-themes. This culminated in the ‘Perceived Effectiveness of Training’ (PET) framework. Whilst developing an explanatory account of the data, it became clear that the themes represented three core concepts that need to be considered to optimise training for effectiveness: Interpersonal, Intrapersonal and System. Interpersonal relates to themes that involve other people, including the impact of other people on learning and social factors that influence effective training. Intrapersonal relates to any phenomenon concerned within the individual and incorporates how perceptions, beliefs/attitudes and the ability to process information are influenced by how training is delivered. System describes how training is evaluated in organisational or environmental terms, such as factors relating to the workplace or barriers and facilitators to implementation of the training objectives. These core concepts are akin to interaction between the person (intrapersonal), environment (interpersonal and system) and behaviour outlined in Social Cognitive Theory (SCT) (13), and can be viewed as separate but interrelated categories that influence each other.
The data analysed in Study 2 was found to map closely onto the PET framework. In addition it reflected the core concepts of interpersonal, intrapersonal and system factors as determinants of effective training. Only one sub-theme was not supported, which was ‘mode of delivery’ in the credibility theme. This possibly reflected the context of Study 1 being conducted as part of a training evaluation with some of the responses in interviews being specific to that training. Five new sub-themes emerged during the analysis of Study 2 which extended the PET framework. These included: Social support in ‘Social Interaction’; Dual Processing in ‘Information processing’; Training Practicalities in ‘Practicalities’; Resources in ‘Practicalities’; Reinforcement & Incentives in ‘Practicalities’.
The final PET framework is presented in Fig. 1 below.
Social Interaction
The importance of social learning as a determinant of effective healthcare professional training was evident in both studies, and is widely acknowledge in the education field.
“I like the actual face to face learning, because it allows you to interact with colleagues, and actually, part of learning is actually being able to network and meet other people.” (Study 1, participant 6)
Theories that can be used to explain the effectiveness of social interaction in healthcare professional training include SCT (13, 15), social identity theory (22), Vygotsky’s socio-cultural theory (23) and the theory of planned behaviour (TPB) (24). Socialising and networking and learning from other people in training were strong sub-themes evident in both studies, thus can be seen as important aspects of social interaction that training should aim to encourage. The social influence sub-theme emerged from Study 1 in relation to concerns raised about diffusion of responsibility or social loafing (the reduced contribution to a group task by an individual) in group training. This sub-theme was expanded by the experts who evaluated training components in relation to whether they can instigate social influence and enable social comparison so that individuals are exposed to group norms. Designing a training programme that enables groups of healthcare professional to share examples of good practice may influence individuals’ intentions; the theory of planned behaviour (24) identifies social norms as a predictor of intentions. This also highlights the need to manage negative normative influences on behaviour, as group processes in training may serve to reinforce negative attitudes or reasons not to change the behaviour.
Social anxiety can occur when individuals fear negative evaluation from others. Findings from both studies suggest that training that minimises anxiety and discomfort is perceived more positively by participants, but whether that leads to better learning outcomes remains to be tested empirically. Nonetheless, a challenge for facilitators is to ensure that mastery experiences are offered, as SCT would suggest that negative experiences of training caused by social anxiety could have detrimental effects on self-efficacy (15). Social support from peers and facilitators was identified by experts as important to learning and the implementation of training objectives in practice. Study 1 also identified the importance of training collaborating professionals together which could be one way to encourage social support amongst trainees.
Credibility
Perceived credibility of training as a determinant of effectiveness was another strong theme in both studies.
[ideal training programme] would be some sort of academic theories, again so linked to the actual course they’re delivering, why they are actually delivering it, you know why they’re being trained to deliver this course, selling the evidence... so selling the benefits to the organisation. (Study 2, participant 2)
SCT (13, 15) (specifically the use of modelling techniques and persuasive sources to enhance self-efficacy) and key theories from the persuasion field such as source credibility (25) and the elaboration likelihood model (26) support this finding. The credibility of the facilitator warranted its own sub-theme because of the emphasis placed by participants in both studies on the importance of credible facilitators or trainers as a determinant of effective training, especially in relation to clinical experience and whether facilitators understand the realities of clinical practice. The inclusion of background evidence and/or theory to increase the credibility of the content of the training was also supported in both studies, showing that lecture based presentations that convey evidence and theoretical underpinnings of the new skill or behaviour being covered in training are essential to persuade healthcare professional to adopt a change in practice. Trainers need to acknowledge the difficulties healthcare professional face when trying to practice evidence based medicine in areas where there is uncertainty and present a convincing line of argument with relevant evidence to support whatever the training is trying to achieve. In addition to using credible facilitators and including background evidence to support the content of training, the mode of delivery or how and where training is delivered influenced perceptions of value or worth of a training programme in Study 1, for example off-site training was seen to be more credible by some participants. This in turn could impact on behaviour change in practice so deserves consideration in the training design phase.
Relevance
Perceptions of relevance of the training were important determinants of the perceived effectiveness of the content and process of training in both studies.
“I think the role-play often falls down on the scenario being made up almost and not being kind of true. I think often it can be difficult to get a real sense of a scenario when it’s made up… and it can become quite inconsistent as opposed to what it might be like if it was a real person with that real problem.” (Study 1, participant 1)
SCT (13) states that the capacity of individuals to reflect on past experiences and relate these to current thought processes facilitates understanding and learning. Participants in both studies discussed effective training in terms of the content being clear and relevant, which incorporates the use of suitable training methods and implementation strategies that are seen as relevant to the content of the training, the learning needs of trainees and their work in practice. The need for training to be grounded in reality was a major reason underlying perceptions of training as ‘effective’. There was strong emphasis in both studies that training needs to reflect the reality of trainees’ clinical practice and past experiences. Preparation developed as a distinct sub-theme following emphasis of the importance of preparatory work in order for training to be effective. Experts particularly noted the importance of considering implementation strategies during the preparation stage so training can address possible barriers and facilitators to implementation. The result of preparatory work should lead to the training being perceived as more relevant, but may also result in more credible training. Structured training was also something that underpinned perceptions of effective training in both studies, and is linked to the need for trainees to have clear goals and objectives linked to their own personal learning objectives. This may also increase the relevance of the training with possible repercussions on perceived credibility.
Information processing
Training that incorporates strategies to facilitate information processing was a strong theme in participants evaluations of what makes training effective in both studies.
“I actually like more interactive really, because it makes you more alert, and you’re less likely to let your mind wander off onto other things” (Study 1, participant 6)
Training methods that facilitate, consolidate or hinder the retention of information (memory) were discussed by participants in both studies, showing the need to consider working memory (27) in the design and delivery of training. The need to ensure the engagement of trainees during training was another strong subtheme in both studies and the skills of the facilitator are paramount here. The role of social interaction as a determinant of engagement in training was also clear. Absorbing information was another subtheme evident in both studies: specific training methods were seen to help the absorption of information to enhance learning (e.g. workshops with a mix of training components). The dual processing sub-theme identified in Study 2 is underpinned by dual processing theories (26, 28, 29), which consider whether behaviour is automised/routinised or whether it requires more conscious effort to re-enact. Experts discussed how this might be linked with behaviour change, and that training content should be considered in relation to the nature of the behaviour in question and whether it needs to become more habitual/routinised or whether habitual behaviour in practice is a barrier to achieving the aims of the training. Training should be focused on implementation and consider ways that might encourage the new behaviour(s) to become more habitual.
Practicalities
This theme relates to how training fits with the working practices of trainees, and environmental issues that might affect the quality of training. SCT (13, 15) supports this theme as a determinant of effective training, as environmental factors interact with the person to influence behaviour. Such factors include practical aspects of training and implementation that can act as barriers or facilitators,
“Say you have a practice nurse from a GP practice, and they come and they do the training and they are very enthusiastic and they go back into the workplace very motivated but unless that working environment, the structure of that working environment is amenable to accommodating that new training, delivering the result of that training, then it just dissipates and practice doesn’t change” (Study 2, participant 1)
Participants in both studies discussed the need for training to be kept in-line with the working practices of trainees so that it causes minimal disruption and is seen as relevant to their work. There is some overlap with the relevance theme here, but these responses relate to more practical issues or system related issues that training should address. This theme was expanded quite significantly in Study 2, as practical issues relating to training were often mentioned by experts in relation to the perceived effectiveness of different aspects of training, which may reflect growing concerns with pragmatism and the need to address system barriers to behaviour change in the implementation field. This led to a new sub-theme, training practicalities, which encompasses practical matters important in relation to training itself, such as the benefits of on-line training when it needs to be delivered to large numbers. Having adequate resources to conduct training and implement training objectives was another practical need raised by experts in Study 2, who discussed how resources can influence the training methods and setting of the training and how this can affect the effectiveness of training. Finally, the reinforcement and incentives sub-theme describes experts’ view that incentives can affect training attendance and behaviour change in practice, informed by substantial evidence from the behaviourist approach in psychology and the beneficial effects that positive reinforcement has on learning and behaviour (30). However, there were also some issues raised about the type of reinforcement that is most effective and the potential dangers or unintended consequences of using financial incentives to change behaviour, including creating expectations that it is only worth doing if they are paid to do it, thereby reducing intrinsic motivation.
Links between themes
The PET framework aims to show distinct factors underlying effective training, however themes are likely to interact. Themes that are especially related are social interaction and information processing (specifically engagement) and credibility and relevance, with perceptions of relevance likely to influence perceptions of credibility of the training. The core concepts (intrapersonal, interpersonal and system) can explain these interactions between themes; for example, social interaction in training can impact on an individual’s learning and behaviour. It became clear during the analysis that all of the themes can be influenced by both the content and process (i.e. how it is delivered) of training. A key finding of this research was the centrality of the role played by the facilitator in delivering effective training. A highly skilled and knowledgeable facilitator can exert positive influences on all of the main themes in the PET framework and if necessary, their interjections can counteract a number of detrimental processes that would otherwise undermine training effectiveness.
Training intervention component (TIC) taxonomy
A range of training methods and implementation strategies were identified as having a positive impact on each theme/subtheme in the PET framework. These are presented in additional file 1, which can be used to identify training components that can address each theme in the framework.
The training intervention component (TIC) taxonomy is presented in supplementary file 2. The TIC taxonomy comprises a total of 171 training components (an overview of the taxonomy is shown in Box 1 below).
Box 1 - Overview of the TIC taxonomy showing the grouping labels and the number of training components identified in each group:
Phase | Groupings | Number of training components |
Pre-training | Pre-training planning/preparation | 14 |
Incentives to attend training | 3 |
Training delivery | Content | 7 |
Training methods | 82 |
Characteristics of the training provider/facilitator | 38 |
Characteristics of the recipients | 6 |
Length/duration | 4 |
Characteristics of the setting | 3 |
Post-training | Evaluation | 5 |
Skills transfer techniques | 6 |
Leadership | 3 |
The training components in the ‘content’ group includes intervention strategies to inform the content (i.e. subject matter) of training as it is being delivered as opposed to behaviour change techniques or strategies which are described in other taxonomies (8). The term ‘training methods’ incorporates modes of delivery, exercises and activities and was used instead of ‘format’ to highlight the range of intervention components that can be used in the delivery of training. The term ‘length/duration’ reflects the duration (number of sessions) and intensity (contact time) as described by Davidson et al. (10).